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goal: To educate the pharmacy team about the CDC guideline for prescribing opioids for chronic pain.

After participating in this activity, pharmacists will be able to:> Discuss the impetus for developing

and implementing pain management guidelines during this period of epidemic opioid overdose

> Outline the CDC’s recommendations as presented in its 2016 Guideline for Prescribing Opioids for Chronic Pain

> Discuss talking points and approaches to work with prescribers and ensure patient safety when opioids are prescribed

> List patient counseling points regarding the safe use of opioids

> Identify factors which put patients at highest risk of overdose who may need rescue medication

After participating in this activity, pharmacy technicians will be able to: > Describe the principles behind careful

pain management

> List common mechanisms used to safeguard opioid use

> Recognize when to refer patients to the pharmacist for issues related to pain management or risk of overdose

the university of connecticut school of pharmacy is accredited by the Accreditation council for pharmacy Education as a provider of continuing

pharmacy education.

Pharmacists and pharmacy technicians are eligible to participate in the knowledge-based activity, and will receive up to 0.2 Ceus (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the Cpe Monitor online system and your participation will be recorded with Cpe Monitor within 72 hours of submission.

acPe# 0009-9999-17-003-h01-PacPe# 0009-9999-17-003-h01-t

grant funding: None

activity fee: There is no fee for this activity.

initial releaSe date: march 10, 2017

eXpiration date: march 10, 2019

to obtain Cpe credit, visit www.drugtopics.com/cpe and click on the “take a Quiz” link. this will direct you to the uConn/Drug Topics website, where you will click on the online Ce Center. use your naBp e-profi le id and the session code: 17Dt03-fXK22 for pharmacists or the session code: 17Dt03-tPv68 for pharmacy technicians to access the online quiz and evaluation. First-time users must pre-register in the online Ce Center. test results will be displayed immediately and your participation will be recorded with Cpe Monitor within 72 hours of completing the requirements.

for questions concerning the online cpe activities, e-mail: [email protected].

educational obJectiveS

an ongoing ce Program oF THE uNiVErsiTY oF coNNEcTicuT

scHooL oF pHArmAcY AND DRUG TOPICS

AND

EARN CE CREDIT FOR THIS ACTIVITY ATWWW.DrugTopics.com/cpE

2CPeCRedits

IntroductionApproximately 11% of adults in the United States suffer from daily (chronic) pain, and another 10% have reported severe pain.1 This pain is often severe enough to cause wors-ening health, increased use of healthcare resources, and disability. Results of random-ized clinical trials of opioids for treatment of pain have shown their effectiveness when used in the short term (<12 weeks).2 However,

the benefi t of long-term use (>3 months) is lim-ited.3 Despite this data, opioids are often used to treat chronic pain, with 1 in 5 adults with noncancer–related pain prescribed opioids.4 In fact, the rate of prescribing opioids for pain nearly quadrupled from 1999 to 2014.5 At the same time, prescription opioid deaths from both illicit opioids and misuse of prescription opioids have tripled.6

Thus, the US is in the midst of an opioid over-

FACULTY: dr. holle is associate clinical professor, department of pharmacy practice, university of Connecticut, Storrs, Conn, and associate professor, department of Medicine, university of Connecticut School of Medicine, Farmington, Conn.

FACULTY DISCLOSURE: dr. Holle has no actual or potential confl icts of interest associated with this article.

DISCLOSURE OF DISCUSSIONS OF OFF-LABEL AND INVESTIGATIONAL USES OF DRUGS: this activity may contain discussion of unlabeled/unapproved use of drugs. the con-tent and views presented in this educational program are those of the faculty and do not necessarily represent those of Drug Topics or university of Con-necticut School of pharmacy. please refer to the offi cial prescribing information for each product for discussion of approved indications, contraindica-tions, and warnings.

Abstract Daily (chronic) pain is common among adults living in the united states. it is often treated with opioids despite the lack of evidence for long-term benefi t. given the opioid overdose epidemic in the us, the centers for Disease control and prevention has created evidence- and expert-opinion–based guidelines for prescribing opioids for chronic pain. The overall guideline has been developed to help identi-fy the risks and benefi ts of opioid therapy and improve long-term safety. included are 12 recommendations on determining when to use opioids for chronic pain; optimal prescribing (selection, dosage, duration, fol-low-up, discontinuation); and assessing risk and addressing harms of opioid therapy. The pharmacy team, both pharmacists and pharmacy technicians, have an important role in counseling patients about the safe use of opioids. The team can also work with prescribers to ensure their optimal and safe use in patients with chronic pain. identifi cation of factors putting patients at high risk for opioid overdose and methods to min-imize those risks are provided.

Pharmacist perspective on the CDC guideline for prescribing opioids for chronic painLisa M. Holle, pharmd, BCop, FHopaAssociATE cLiNicAL proFEssor, DEpArTmENT oF pHArmAcY prAcTicE, uNiVErsiTY oF coNNEcTicuT scHooL oF pHArmAcY, sTorrs, coNN, & AssociATE proFEssor, DEpArTmENT oF mEDiciNE, uNiVErsiTY oF coNNEcTicuT scHooL oF mEDiciNE, FArmiNgToN, coNN.

DrugTopics.com | MARCH 2017 | DrugTopics 55

Pharmacist PersPective on the cDc guiDeline for Prescribing oPioiDs for chronic Pain

dose epidemic. In an effort to curb this epidemic, the Centers for Disease Con-trol and Prevention (CDC) created guide-lines for prescribing opioids for chronic pain. The “CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016” has been developed to improve communication between clinicians and patients about the risks and benefi ts of opioid therapy for chronic pain, improve safety and effectiveness of pain treat-ment, and reduce the risks of long-term opioid therapy (Table 1 ).7 The guideline is intended for use by primary care clinicians treating adult patients with noncancer or nonpalliative/end-of-life chronic pain in an outpatient setting. Other pain-related guidelines, however, should be used for patients with cancer or palliative chronic pain, patients with acute pain, and by spe-cialists such as emergency clinicians or dentists.8–11 This article provides an over-view of the guideline and provides the pharmacy team with the tools they need to apply it to their practice.

CDC guideline developmentThe CDC used the Grading of Recommen-dations, Assessment, Development, and Evaluation (GRADE) method for guideline development.7 This method allows the quality of available evidence to be graded and the guideline recommendations to be placed into categories based on the quality of evidence, balance of benefi ts and harm, values and preferences, and resource allo-cation. The evidence type is graded from type 1 (highest level of evidence, eg, ran-domized clinical trials or overwhelming evi-dence from observational studies) to type 4 (clinical experience and observations or studies with major limitations). The cat-egory of recommendations was either A (applies to all patients and patients should receive) or B (requires individual deci-sion making to apply to different patients). CDC initially obtained input from experts, stakeholders, the public, and a federally chartered advisory committee and then obtained individual perspectives from sub-ject experts, primary care professional society representatives, and state agency representatives.

The clinical evidence review consisted of an update to the systematic review spon-sored in 2014 by the Agency for Healthcare Research and Quality (AHRQ) on effec-tiveness of long-term opioid treatment of chronic pain. It addressed the key ques-tions of effectiveness and comparative effectiveness, harms and adverse events, dosing strategies, risk mitigation strate-gies, and effect of opioid use for acute pain on long-term use.7,12 Overall, this updated clinical evidence review showed that insuf-fi cient evidence exists supporting long-term opioid use for chronic pain because of the lack of documented long-term benefi ts and the risk of serious harm. Key fi ndings are summarized here, but full details can be found in the guideline including grading of the evidence.

The updated review confi rmed that no randomized studies on the use of opioids for chronic pain have evaluated long-term (ie, ≥1 year) outcomes related to pain, function, or quality of life. Most placebo-controlled studies have been 6 weeks or shorter in duration. Long-term opioid use, however, was associated with opi-oid abuse or dependence (ie, unsuccess-ful efforts to reduce or control use, result-ing in failure to fulfi ll major role obligations at work, school, or home), risk of fatal and

nonfatal overdose, cardiovascular events, endocrinologic harms, and road trauma.

Dosing strategies were evaluated in this clinical review, but outcome results were inconsistent. One study found that using an extended-release/long-acting (ER/LA) formulation rather than initiat-ing therapy with an immediate-release (IR) opioid was associated with greater risk of overdose, particularly during the fi rst 2 weeks of therapy. Accuracy of risk assessment tools to identify patients at

risk of opioid abuse/misuse was deter-mined to be inconsistent, and no stud-ies evaluating risk mitigation strategies were found. Finally, studies showed that patients undergoing low-risk surgery or those with injury-related low back pain who received opioids were more likely to have long-term opioid use than those treated for other acute pain episodes.

Based on the updated AHRQ systemic review and an additional contextual evi-dence review assessing the benefi ts and harms of opioid therapy, values and preferences of providers and patients, resource allocation, and effectiveness of nonpharmacologic and nonopioid thera-pies, 12 recommendations were made. These were grouped into 3 categories: 1) determining when to use opioids (initiate or continue) for chronic pain; 2) prescrib-ing opioids (selection, dosage, duration, follow-up, discontinuation); and 3) assess-ing risk and addressing harms of opioids.

When to use opioids in chronic pain Opioids should not be considered fi rst-line therapy for routine treatment of chronic pain that is not pain due to active cancer or for palliative/end-of-life care because of the small-to-moderate short-

term benefi t, uncertain long-term bene-fi ts, and serious risks. Instead, nonphar-macologic therapy, such as weight loss, exercise therapy, cognitive behavioral therapy, and interventional approaches, should be used to reduce pain and improve function in patients with chronic pain. For example, high-quality exercise therapy for hip or knee osteoarthritis has been shown to sustainably reduce pain and improve function for 2 to 6

The ‘cDc guideline for prescribing opioids for chronic pain–united states, 2016” is intended for use by primary care clinicians treating adult patients with noncancer or nonpalliative/end-of-life chronic pain in an outpatient setting.

C o n t i n u e d o n p a g e xx >

Peer Reviewed Continuing Education


CDC Guidelines Recommendations for Prescribing Opioids for Chronic Pain

ReCoMMendAtion CAtegoRY*

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. clinicians should consider opioid therapy only if benefi ts for both pain and function are anticipated to outweigh risks to patient. if opioids are used, they should be combined with nonpharmacologic therapy and nonopioid therapy, as appropriate.

categorY aevidence type 3

Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with patients, including realistic goals for pain and function and should consider how opioid therapy will be discontinued if benefi ts do not outweigh risks. They should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.


Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefi ts of opioid therapy and patient and clinician responsibilities for managing therapy.


When starting opioid therapy for chronic pain, clinicians should prescribe ir opioids instead of Er/LA opioids. categorY aevidence type 4

When opioids are started, clinicians should prescribe lowest effective dosage. They should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefi ts and risks when considering increasing dosage to ≥50 mmE/day, and avoid increasing to ≥90 mmE/day or carefully justify decision to titrate to ≥90 mmE/day.


Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of ir opioids and no greater quantity than needed for the expected duration of pain severe enough to require opioids. often suffi cient will be <3 days; >7 days will rarely be needed.


clinicians should evaluate benefi ts and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or dose escalation. They should evaluate benefi ts and harms of continued therapy with patients every 3 months or more frequently. if benefi ts do not outweigh harms of continued therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or taper and discontinue opioids.


Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. They should incorporate into management plan strategies to mitigate risk, including considering offering naloxone when factors increasing risk for opioid overdose, eg, history of overdose, substance use disorder, higher opioid dosages (≥50 mmE/day), or concurrent benzodiazepine use, are present.


clinicians should review patient’s history of controlled substance prescriptions using pDmp data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at risk for overdose. pDmp data should be reviewed when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.


When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications and other controlled prescription drugs and illicit drugs.

categorY bevidence type 4

clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. categorY aevidence type 3

clinicians should offer/arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder.


Abbreviations: ER/LA, extended-release/long-acting; IR, immediate-release; MME, morphine milligram equivalents; PDMP, prescription drug monitoring program.*Category A, applies to all persons; most patients should receive recommended course of action; Category B, individual decision making needed; different choices appropriate for different patients. Clinicians help patients arrive at decision consistent

with patient values/preferences and specific clinical situations. Level 1, randomized clinical trials or overwhelming evidence from observational trials; Level 2, randomized clinical trials with important limitations or exceptionally strong evidence from observational trials; Level 3, observational studies or randomized clinical trials with notable limitations; Level 4, clinical experience and observations or studies with major limitations Source: Ref 7

TABLE 1

months.13,14 This has also been found to be true in patients with low back pain and fi bromyalgia.13,15 The pharmacy team can encourage patients to work with their pri-mary care team to have an active role in developing their care plan and support patients engaging in exercise.

When nonpharmacologic therapy alone is not enough to improve pain and function, consider nonopioid pharmaco-logic therapy, such as nonsteroidal anti-infl ammatory agents (NSAIDs), acetamin-ophen, selected antidepressants, and anticonsulvants.7 Acetaminophen and NSAIDs are effective for osteoarthritis and low back pain. Pregabalin and gab-

apentin have proven effi cacy in diabetic neuropathy and postherpetic neuralgia. Other types of neuropathic pain have been effectively treated with pregaba-lin, gabapentin, carbamazepine, tricyclic antidepressants, and serotonin norepi-nephrine reuptake inhibitors. Pregabalin and duloxetine can be effective in treat-ing pain associated with fi bromyalgia.

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Nonopioid drugs are generally not asso-ciated with substance use disorders or are rarer causes of overdoses compared with opioids. Yet these drugs are not with-out risks, particularly in geriatric patients and those with cardiovascular, renal, gas-trointestinal, and/or liver disease. Thus, clinicians should individualize therapy based on benefit versus risk. For more information, see a previously published Drug Topics article and CDC guideline resources.16,17

For complex pain syndromes, specialty teams should be consulted for diagnosis and management. Pain associated with diseases like diabetes and rheumatoid arthritis may be ameliorated by improv-ing disease control (eg, glucose control with diabetes to prevent progression of diabetic neuropathy, immune-modulat-ing therapy for rheumatoid arthritis).7 In some situations, opioids may indeed be appropriate even if the patient has not failed nonpharmacologic or nonopioid therapy as long as the expected bene-fits have been weighed against the risks. For example, in a patient with serious ill-ness and poor prognosis who has contra-indications to nonopioid pharmacologic therapies and the goal of care is comfort, opioids may be an appropriate option as long as patient and provider have dis-cussed benefits and risks.

If opioids are determined to be appro-priate, they should be combined with non-pharmacologic therapy and nonopioids as appropriate and the patient and pro-vider should develop treatment goals. The review of clinical evidence did not find studies evaluating written agreements or plans, yet those who set a plan in advance will be able to clarify expectations of opioid therapy (eg, how prescribed, monitored, when doses are discontinued or tapered if goals not met). Treatment goals would ideally include improvements in both pain relief and quality of life and/or function (physical, emotional, psychologic). Vali-dated instruments such as the pain aver-age, interference with enjoyment of life, and interference with general activity (PEG) assessment scale can be used to track outcomes.18 PEG uses an 11-point visual

analog scale to have the patient describe their average pain in the past week; how the pain interfered with enjoyment of life in the past week; and how the pain interfered with general activity in the past week. Studies have shown that a clinically mean-ingful improvement for pain and function is 30%.19

Despite the updated AHRQ review not revealing studies evaluating effectiveness of patient education and risk-mitigation strategies, the contextual evidence review found that many patients lack informa-tion about opioids and identified concerns that clinicians have missed opportunities to discuss safety issues. Table 2 provides important considerations in patient edu-cation about opioid therapy.7,20

Safely prescribing opioidsIR opioids, rather than ER/LA opioids (eg, extended-release opioids, methadone, transdermal fentanyl) should be used for initiation of opioid therapy for chronic pain. The risks of overdose are higher with

ER/LA opioids, and no difference in effi-cacy or safety was observed between con-tinuously scheduled ER/LA opioids and intermittent use of IR opioids.7,21 An ER/LA opioid should be reserved for patients with severe, continuous pain who have received IR opioids daily for at least 1 week. When selecting an ER/LA opioid for a patient, the guideline recommends avoiding methadone and transdermal fen-tanyl unless the clinician is familiar with the unique risk profiles of these drugs (ie, unpredictable pharmacokinetics/dynam-ics of methadone, dosing/absorption properties of fentanyl). Unlike in patients with cancer pain or opioid use for palliative or end-of-life–related pain, it is not recom-mended to routinely prescribe an IR opi-

oid with an ER/LA opioid for breakthrough pain because of the lack of evidence sup-porting its safe combined use. Some patients may benefit from the combina-tion, however, and this should be individu-alized after assessing risks and benefits.

The lowest possible opioid dose should be selected for initial therapy. Opioid over-dose risk increases in a dose-response manner: doses 50–100 morphine milli-gram equivalents (MME)/day increase risk 1.9 to 4.5 times and 100 MME/day or more increase risk 2 to 8.9 times compared with less than 20 MME/day.7 Based on this data, the CDC guideline recommends that the overdose risk is reduced (although not eliminated) if the dose is kept at less than 50 MME/day. Again, this is only true for patients with noncancer –related chronic pain. It is also important to understand that geriatric patients and those with renal or hepatic insufficiency will likely have decreased clearance of opioids, and thus low doses and small increases are recommended.

When changing doses of opioids, the gen-eral rule is to wait at least 5 half-lives of the drug before making a dose change.22 For patients whose doses escalate above 50 MME/day in an effort to control pain and improve function, clinicians should reassess whether opioid treatment is the best approach. Other methods of pain management may be more beneficial. Some states have requirements for MME thresholds or associated clinical docu-mentation (eg, Washington state requires a pain specialist consult for any prescrip-tion >120 MME/day).23

Continual reassessment of effec-tiveness, adverse effects, and harm risks is necessary for all patients receiv-

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a patient arrives at your community pharmacy with a new prescription for immediate-release oxycodone 5 mg every 6 hours as needed for low-back pain. What patient education would you provide this patient at the time of dispensing?

pAuse And pondeR



ing opioids. Opioid therapy lasting lon-ger than 3 months is associated with an increased risk of opioid-use disorder, and patients without pain relief at 1 month are unlikely to have pain relief with opi-

Patient education for opioid use in Patients with chronic Pain


TABLE 2

be explicit and realistic about expected benefi ts of opioids ê opioids reduce short-term painê unknown benefi t of opioids to improve pain and function with long-term use ê Complete pain relief is unlikely

emphasize improvement in function is primary goal and functional improvement can occur even when pain is present

discuss potential serious side effectsê Fatal respiratory depressionê development of life-long opioid-use disorder

advise about common side effects and how to mitigateê CONSTIPATION: increase hydration and fi ber intake, and maintain or increase physical activity to prevent constipa-tion. Stool softeners or laxatives should be taken regularly with eR/La opioids and may be needed with iR opioids.ê DRY MOUTH: chronic dry mouth can lead to tooth decay. advise patients to use regular and gentle dental hygiene and have regular dental visits. Saliva substitutes may be considered.ê NAUSEA AND/OR VOMITING: usually transient lasting 2–3 days after opioid initiation in some but not all patients; as-needed antiemetics may be provided. Chronic nausea may occur in 15%–30%; switching to another opioid may eliminate nausea.ê DROWSINESS: usually transient after opioid initiation and dose escalation until tolerance is developed. avoid driv-ing during these periods.ê CONFUSION: usually transient after opioid initiation and dose escalation until tolerance is developed, typically after a few days and sometimes a few weeks. if not resolving, talk with provider to rule out other causes.ê TOLERANCE: defi ned as diminished response to a drug with repeated use that may require patient to need higher doses of opioids over time.ê PHYSICAL DEPENDENCE: defi ned as adaptation to a drug that produces symptoms of withdrawal when drug is stopped. emphasize to patient that physical dependence is not addiction, but means they should not abruptly stop opioids and work with provider to gradually taper off at time of discontinuation to avoid withdrawal symptoms.

discuss that opioids impair ability to safely operate a vehicle, particularly when opioids are initiated,doses increased, or when other cnS system depressants, eg, benzodiazepines or alcohol, are concurrently used

discuss importance of taking dose of opioids as prescribed because of risk of serious side effects with ê Higher doses or taking more often than that prescribedê use with other medications: benzodiazepines, sedatives, alcohol, illicit drugs

discuss risks to household members and others if opioids are intentionally or unintentionally shared, and include discussion of

ê proper storage in a secure, preferably locked locationê options for safe disposal of unused opioidsê availability and proper use of naloxone for overdose reversal (consider prescribing/dispensing if state regulations allow)

discuss importance of periodic reassessment to ensure goals are met and/or consideration of other alternatives if opioids are not effective or harmful

discuss planned use of precautions to reduce risk ê prescription drug monitoring programê urine drug testing (if used)

*During patient education session, consider if cognitive limitations interfere with management. If so, contact prescriber to discuss if caregiver can responsibly comanage therapy.Abbreviations: CNS, central nervous system; ER/LA, extended-release/long-acting; IR, immediate-release. Source: Refs 7,20

oids at 6 months.7 Furthermore, opioid overdose risk is greatest within the fi rst 3 to 7 days following opioid initiation or dosage increases, especially with meth-adone and transdermal fentanyl. Thus, it is important for clinicians to evaluate patients continually while receiving opi-

oid therapy. Initial follow-up should occur within the fi rst 3 days in patients initiating or dose escalating methadone or trans-dermal fentanyl, and within 1 week for patients initiating or dose escalating IR or ER/LA opioids. At follow-up, clinicians should assess benefi ts in function, pain control, and quality of life. Tools such as the PEG assessment scale can be used. Adverse effects such as constipation and drowsiness, and warning signs of over-dose (eg, sedation or slurred speech) or opioid-use disorder (eg, craving, using larger-than-prescribed quantities) should also be assessed. Finally, patients should be asked about their preference to continue opioids, given their effects on pain/function and adverse effects. If opioids are continued, reassess-ment should take place. The optimal fre-quency, however, is unknown. With dose escalations, the guideline recommends a follow-up reassessment for most opioids within 1 to 4 weeks of the dose escala-tion. However, for methadone, this follow-up reassessment should be done within 3 days and when total daily opioid dose is 50 MME/day or greater, follow-up reas-sessment should be done within 1 to 2 weeks. When a patient is on a stable dose, reassessment is recommended at least every 3 months. Ideally, the reas-sessments take place in person, but that may not always be possible.

If clinically meaningful improvements in pain and function are not achieved or sus-tained, or the balance of harms outweigh the benefi ts, patients may need to be tapered off opioids and nonpharmacologic or nonopioid pharmacologic treatment should be used or a pain specialist con-sulted. Patients should not self-taper off of opioids. The AHRQ clinical evidence review did not fi nd any high-quality studies com-paring effectiveness of different opioid-tapering protocols.12 Previously published guidelines recommend reducing weekly dosage by 10% to 50% of original dos-age.24 Rapid dose escalations over 2 to 3 weeks can be accomplished with severe adverse drug reactions, and slower tapers of a 10% dose reduction per week or month may be better tolerated in patients



who have been on opioids for years. Essen-tially, the idea is to taper slowly enough to minimize withdrawal symptoms (eg, drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydria-sis, tremor, tachycardia). Individualizing the taper is reasonable based on patient goals, concerns, and ability to follow direc-tions. It may be that the taper needs to be paused and restarted when patients reach low dosages to avoid withdrawal symp-toms. When the smallest available dose is reached, the interval can be extended, and opioids can be stopped when taken less frequently than once per day. Before a taper starts, clinicians should discuss with patients the increased risk of overdose with an abrupt return to their starting dose. They should also provide detailed educa-tion about the taper schedule, withdrawal symptoms, and whom to contact if any questions/withdrawal symptoms occur. Several resources are available for sug-gested tapering and discontinue sched-ules.25–28

Opioid use for acute pain —pain with abrupt onset and caused by injury or sur-gery—has been associated with long-term opioid use.7 Although acute pain can often be managed without opioids, in some cases opioids can be benefi-cial, such as following surgery or trauma. When opioids are used, the CDC guide-line recommends providing a duration that is appropriate for the expected dura-tion of the pain. For example, for most sur-gical pain, often 3 days or less of opioid therapy is sufficient and more than 7 days is rarely needed. Rather than prescrib-ing opioids for the “just in case” situation, clinicians should be prepared to re-eval-uate patients who have persistent pain to determine appropriate management. Only IR opioids should be used. This prac-tice not only eliminates the potential for

physical dependence but also minimizes the number of leftover pills available for unintentional or intentional diversion.

Assessing risk and addressing harms of opioid useDespite the clinical evidence review pro-viding insufficient evidence as to how best to determine harms of opioids based on specific patient comorbidities or demographics, the panel (based on contextual evidence and expert opinion) recommend that certain risk factors are likely to increases susceptibility to opioid-related harms.7 Table 3 lists the high-risk groups for opioid use in chronic pain man-agement.7 It also provides recommen-dations for these groups when consider-ing opioid therapy. Assessing risk factors should be done periodically and may dif-fer depending on the risk. For example, factors such as alcohol use can vary over time and require more frequent follow-up. Simple questions can be used to assess drug and substance abuse. For example, the question “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedi-cal reasons” has been shown to be 100% sensitive and 74% specific for detecting a drug use disorder when compared with standardized diagnostic interviews. Other methods for assessing risk and address-ing harms of opioid use include reviewing the prescription drug monitoring program (PDMP), urine drug testing, avoiding pre-scribing and use of opioids and benzodi-azepines concurrently, offering naloxone for opioid reversal, and referral or treat-ment for opioid-use disorder.

Reviewing the PDMP. PDMP are state-wide electronic databases that collect, monitor, and analyze controlled sub-stance prescribing and dispensing data submitted by pharmacies and dispens-

ing providers. Operational PDMPs are cur-rently available in 49 states, the District of Columbia, and Guam.29 Missouri is the only state that does not have a currently operational PDMP. All PDMPs collect information about schedule II to IV con-trolled substances, and 35 states also collect information about schedule V con-trolled substances. Some states require providers to review the PDMP before pre-scribing opioids. The timeliness of trans-mitted data as well as requirement pol-icies, however, vary from state to state. For example, in Connecticut, authorized agents of the prescriber, including phar-macists who may work with the provider, are allowed to review the PDMP data on behalf of the provider.30 This may assist with provider workload and allow timely assessment of risk.

Because opioid overdoses often occur in patients receiving opioids from multi-ple providers and/or with high total daily dosages of opioids, it is prudent to review this information during the risk assess-ment before initiating and during opi-oid therapy. Ideally, the PDMP should be reviewed before each prescription is writ-ten. In states where the PDMPs are not fully functional with timely data transmis-sion, however, this may not be possible. Thus, the guidelines recommend review-ing the PDMP at least every 3 months, unless factors that increase the opioid-related harms are not present and it is not required by state law. The review should include data for opioids and other con-trolled substances. This will allow the cli-nician to evaluate the total opioid dosage and dangerous combinations (eg, benzo-diazepines and opioids) that may increase risk of opioid overdose. PDMPs require community pharmacists to submit elec-tronic data related to dispensing of con-


if clinically meaningful improvements in pain and function are not achieved or sustained, or the balance of harms outweigh the benefits, patients may need to be tapered off opioids and nonpharmacologic or nonopioid pharmacologic treatment should be used or a pain specialist consulted.




trolled substances within a timely manner as determined by state law. Community pharmacists, however, can also review the PDMP prior to dispensing a controlled substance prescription and alert the pro-vider if risks are identifi ed before dispens-ing the prescription as well as discuss safety concerns with the patient.

If high opioid dosages, multiple con-trolled substance prescriptions, or dan-gerous combinations are found, the phar-macist should attempt to improve the patient’s safety. Information gained from reviewing the PDMP should be discussed with the patient. Occasionally, information may be incorrect, particularly if the wrong name or birthdate was entered or another person has used the patient’s identity to fi ll a prescription. When high total MME/day dosages are calculated, the clinician should have a discussion with the patient about safety concerns and possibility of taper to a safer dose. If dangerous combi-nations are identifi ed, the clinician should initiate a discussion with other provid-ers involved in prescribing the medica-tions and then with the patient if the com-bination is deemed necessary, such that the patient understands the risks. In the case of a possible substance use disor-der, discussing concerns and referring the patient to a program is important. Finally, if suspicion exists that the patient is shar-ing or selling the opioids, clinicians should consider urine drug testing to determine whether opioid cessation can occur with-out inducing withdrawal.

Urine drug testing. Clinicians can employ urine drug testing to provide infor-mation about drug use that the patient has not reported and opioid nonadher-ence.7 Urine drug testing, however, does not provide accurate information on dose or quantity of opioids used, is sub-ject to misinterpretation, can sometimes be used to harm patients (eg, stigmati-zation), increases costs to patients, and requires clinicians have the appropriate training and time to effectively interpret, confi rm, and communicate results. The guideline experts did recommend urine drug testing before initiating opioids and periodically during therapy (at least annu-

ally) certainly for individual patients at high risk. More frequent urine drug test-ing may be appropriate for patients with substance use disorders.

Typically, urine drug testing can be com-pleted using a relatively inexpensive immu-noassay panel that tests for commonly prescribed opioids and illicit drugs. Each institution’s immunoassay may be differ-ent. Thus, it is critical that clinicians under-stand how to interpret the results. For example, a positive “opioid” immunoassay typically detects morphine. This may not only refl ect a patient’s use of morphine but also codeine and heroin, because these drugs are metabolized into morphine. Fur-thermore, synthetic opioids (eg, fentanyl or methadone) are not detected and semi-synthetic opioids (eg, oxycodone) may not be either. Use of confi rmatory tests, tests which confi rm a positive or negative urine drug test typically using gas chromatog-raphy/mass spectometry, should only be completed when there is a need to detect specifi c opioids not available on standard assays or the presence of unexpected results. Guidance on interpreting results can be found in previously published guide-lines and a Drug Topics article.23,31

Clinicians should also have a plan in place for how to handle the results of urine drug tests before ordering the tests. For example, before the urine drug test is done, clinicians should explain the test-ing is done to improve patient safety and ask the patient about how they are using prescribed drugs, and if and how they are using any other drugs (nonprescribed or even illicit drugs). It is also recommended to ask the patient “should I expect an unexpected result on the urine drug test,” as this can allow the patient to provide important information about any changes in their use of opioid drugs that may affect the urine drug test results. If unexpected results occur, initiating a similar post-test-ing discussion can be useful to reveal important information about why a par-ticular result was reported before the cli-nician determines whether confi rmatory testing is needed, which is expensive and may be unnecessary. Unexpected results also offer the clinician the opportunity to

improve patient safety by tapering/discon-tinuing opioids; more frequent monitoring and evaluation; offering naloxone; and/or referral for substance use disorder.

Avoiding benzodiazepines and opioids. Because both benzodiazepines and opi-oids cause central nervous system (CNS) depression and a decrease in respira-tory drive, the likelihood of a fatal over-dose is increased.7 Thus, in general, ben-zodiazepines should not be prescribed in patients using opioids for chronic, non-cancer-related pain. Some situations may be appropriate for concurrent use, such as severe acute pain in patients taking stable low-dose benzodiazepine therapy. Other CNS depressants, such as mus-cle relaxants and hypnotics, may also be risky. Clinicians should evaluate benefi t versus risk for individual patients.

Checking the PDMP before initiating opioids will allow the clinician to identify concurrent CNS depressants and involve pharmacists and/or pain specialists to assist with determining risk/benefi t and developing a plan for discontinuing the CNS depressants. Coordinating care with mental health professionals is also criti-cal, as they may be able to assist with pri-oritizing patient goals and coordination of care. Benzodiazepines require a gradual taper in patients who have been on long-term therapy to avoid rebound anxiety, hallucinations, seizures, and delirium. Several tapers have been published, but a common regimen includes a 25% dose reduction every 1 to 2 weeks depending on patient symptoms.32 Cognitive behav-ioral therapy can greatly improve the suc-cess rate of benzodiazepine tapering.

Opioid-use disorder treatment. If patient behaviors, information gained from PDMP review, or results from urine drug testing suggest a possible opioid-use disorder, clinicians should discuss these concerns with the patient. This allows the patient an opportunity to disclose related concerns or problems. Patients who meet the criteria for opioid-use disorder accord-ing to the Diagnostic and Statistical Man-ual of Mental Disorders (DSM-V) should receive evidence-based treatment.33 Typi-cally, this will be medication-assisted ther-



apy with buprenorphine or methadone maintenance therapy along with cognitive behavioral therapy. Oral or long-acting nal-trexone may be an option in nonpregnant women. Patient costs may be a barrier for buprenorphine therapy, given that insur-ance plans often do not cover buprenor-phine for opioid-use disorder. In these patients, offering naloxone for an opioid overdose is also recommended. Some patients may have problematic opioid use but do not qualify according to DSM-V cri-teria for opioid-use disorder. In these patients, tapering and discontinuing opioid therapy is recommended.

Many communities do not offer medi-cation-assisted therapy or maintenance programs, or are over capacity. The guide-lines recommend in these cases that pro-viders consider obtaining a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA) that would allow them to prescribe buprenor-phine in patients with opioid-use disor-der or prescribe naloxone, which does not require a waiver.34 To find opioid treat-ment programs, behavioral health treat-ment services, and buprenorphine phy-sician and treatment programs, see https://www.samhsa.gov/find-help.34

Naloxone. The opioid antagonist nal-oxone can be used to reverse respiratory depression. It is an antagonist at the mu, kappa, and delta receptors and works by displacing opioid agonists at the opioid receptors. Because it has no agonist activ-ity, patients who have not received opioids and receive naloxone have no effects. Cur-rently, 8 FDA-approved formulations are available and only 1 (naloxone hydrochlo-ride injection via Carpuject™) is not recom-mended for lay-person or take-home use because of its complicated assembly. Nal-oxone can be administered for opioid over-dose intranasally, intramuscularly, and subcutaneously.35 Administration by lay persons has been shown to save lives.36 Although naloxone is a prescription prod-uct in the US and the District of Columbia, accessibility varies from state to state. In many states, providing naloxone to lay per-sons who might witness an overdose in


High-Risk Groups and Opioid Use

HigH-Risk gRoup CoMMents/ReCoMMendAtions

Sleep-diSordered breathing (eg, Sleep apnea)

ê Risk factors: CHF, obesityê Carefully monitor during opioid therapyê Cautious opioid dose titrationê avoid prescribing if moderate–severe disorders

pregnancy, breaSt-feeding, reproductive-age women

ê Risk to mother and fetus (eg, stillbirth, poor fetal growth, opioid withdrawal syndrome)ê patients and providers together carefully weigh risks and benefitsê For reproductive-age women, discuss family planning and risks during pregnancyê Consult experts if tapering during pregnancy to prevent patient/fetus withdrawalê use buprenorphine or methadone for pregnant women with opioid-abuse disordersê use a facility prepared to monitor, evaluate, and treat opioid neonatal withdrawal for delivery for neonates in pregnant women receiving opioids, methadone, or buprenorphine ê avoid codeine in breast-feeding women (may cause neonatal toxicity/death). if needed, use lowest possible dose and ≤4-day supply

renal or hepatic inSufficiency

ê use caution and increase monitoring to minimize risks because opioid accumulation may occur

age ≥65 yearS ê Risks: inadequate pain management, reduced renal function, propensity to accumu-late opioids, cognitive impairment, likelihood of drugs that interact because of comor-bid conditionsê use caution and increase monitoringê educate patients to avoid obtaining opioids from multiple providers and saving unused quantitiesê initiate exercise and bowel regimens to prevent constipation, risk assessment for falls, and cognitive impairment monitoring

mental health conditionS

ê assess all patients for psychologic distress using validated instruments for anxiety ptSd, and/or depression (eg, gad-7, pHQ-9, pHQ-4)ê use caution and additional monitoringê do not initiate in patients during acute psychiatric instability or with uncontrolled suicide riskê Consider behavioral health specialist consultation before initiating opioids in patients with history of suicide attempt or psychiatric disorderê avoid benzodiazepines for patients with anxiety or other mental health conditionsê optimize treatment for depression and other mental health conditions, which can improve pain

SubStance uSe diSorder

ê ask about alcohol and illicit drug useê Review pdMp dataê Consider urine drug testing as appropriateê provide counseling about increased risk of overdose when opioids are combined with alcohol or other drugsê ensure patients receive appropriate treatment for substance abuse disorder when neededê discuss risks, consider if benefits outweigh risks in patients with history of substance use disorder before opioids are prescribed. if prescribed, incorporate strategies to mitigate risks, consult with substance use disorder and pain specialists, and offer naloxoneê Communicate with substance use disorder treatment providers if opioids are prescribed

previouS nonfatal overdoSe

ê Work with patient to reduce opioid dosage and discontinue opioids when possibleê discuss increased risk and whether benefits >risks if continued opioid use is needed, incorporate strategies to mitigate risks, and offer naloxone

Abbreviations: CHF, congestive heart failure; GAD, generalized anxiety disorder; PHQ, patient health questionnaire; PTSD, post-traumatic stress disorder. Source: Ref 7

TABLE 3




their family or friends or to service provid-ers (eg, emergency medical personnel, policeman, behavioral health specialists) has been one mechanism.36 Other states have allowed pharmacists to prescribe naloxone, either independently or through collaborative practice agreements, to patients or caregivers of patients receiv-ing opioids. For example, in Connecticut, trained pharmacists are allowed to pre-scribe naloxone to any individual to treat or prevent an overdose as long as appropri-ate documentation is made.37

The guideline recommends that nal-oxone be offered to all patients at increased risk for opioid overdose, includ-ing patients taking benzodiazepines with opioids; patients at risk for returning to a high dose to which they are no longer tol-erant, such as patients recently released from a correctional institution; and patients taking 50 MME/day or more.7 Other experts suggest that offering nal-oxone to all patients receiving opioids is wise, because the risk of an accidental opioid overdose by the patient or some-one else with access to opioids within a home or workplace can occur.38 If nal-oxone is prescribed, appropriate educa-tion about using naloxone and subse-quent steps (eg, calling 911) is essen-tial. This education ideally is provided by prescribers and pharmacies (when the pharmacist is not the prescriber of nal-oxone) to reinforce patient understand-ing. Resources for prescribing naloxone can be found at: http://prescibertopre-vent.org.

Role of pharmacy teamBecause pharmacists and pharmacy technicians are on the front lines of dis-pensing opioid pain medication and pro-viding medication-related services, they are in an optimal position to engage patients and prescribers in prevention and treatment efforts for opioid-use dis-order and overdose.7 In the community pharmacy setting, the pharmacy team often has limited time and patient infor-mation, yet they can play a critical role in

evaluating and identifying risks. Assessing patients with opioid pre-

scriptions for “red fl ags,” such as that the patient may be struggling with opi-oid-use disorder or diverting medications, is feasible. Red fl ags include forged pre-scriptions (ie, lack of common abbrevia-tions; atypical quantities, directions, or dosages; overly legible handwriting); pre-scriptions originating from outside of the immediate geographic area; altered pre-scriptions (eg, multiple ink colors, differ-ing handwriting styles); cash payments; inconsistent or early prescription fi lls; and multiple prescribers.7,39 Other concern-ing and potentially drug-seeking behav-iors include unusual or overly assertive behavior; unkempt or overdressed appear-ance; unusual knowledge of controlled substances; claims of no regular health-care provider or health insurance; calling or coming in after regular hours; claims to be traveling or visiting relatives; claims pre-scription is lost or stolen; or signs of drug abuse, such as skin tracks or scars on neck, arms, feet, or ankles.39 Pharmacy technicians should alert their pharmacist if they identify any of these red fl ags while intaking prescriptions and/or communicat-ing with patients. Additionally, validation of the prescriber DEA registration number and patient identifi cation information can further verify the prescription is not altered. Reviewing the PDMP (if available) and any patient prescription records will allow the pharmacy team to identify multiple pre-scribers, concerning concurrent therapies, and timing of prescription fi lls.

Contacting the prescriber with ques-tions or concerns is vital to ensuring patient safety.7 Keep in mind that with forged prescriptions, a patient may use his or her own phone number. There-fore, it is best to look up the prescrib-er’s phone number instead.38 It is impor-tant to have this conversation in an area where the patient cannot hear, as this is humiliating to those who are truly in need of pain relief and may agitate those who are being fraudulent, placing the whole pharmacy team at risk of violence. When

discussing questions or concerns with providers, it is essential to do so in a col-laborative manner. If the question is not related to a potentially forged prescrip-tion but rather optimal application of CDC guidelines for opioid use in chronic pain, then indicating that there are concerns about patient safety may allow a candid and collaborative conversation. Having a recommendation or drug information sup-porting that recommendation is helpful to facilitate prescriber understanding and addressing any concerns.

Community pharmacists also have a role in assisting with the management of pain and application of these guidelines by educating patients on opioid risks and methods for managing risks. They can work together with providers to review and monitor pain management therapy, assist in implementing treatment plans, and provide drug information and rec-ommendations to the healthcare team based on their pharmaceutical knowl-edge and the guidelines. Because the community pharmacy team may see the patient more frequently than the health-care provider, they can have a role in iden-tifying patients who may not be optimally treated for their chronic pain. If conver-sations with the patient identify that they are not receiving optimal relief or are not concurrently using nonpharmacologic therapy, this may provide an opportunity to intervene and discuss potential ther-apy alternatives or optimization with the patient and providers. The CDC has sev-eral resources available to aid in apply-ing guidelines to clinical care, includ-ing a checklist for prescribing opioids for chronic pain; an opioid prescribing guide-line mobile app; a pocket guide to taper-ing opioids, information on calculating dosages, assessing benefi ts and harms, PDMPs, and nonopioid treatments; and tips for pharmacists. Additionally, there are trainings available, posters, and patient resources. These all can be found at: https://www.cdc.gov/drugoverdose/prescribing/resources.html.

When opioids are dispensed, consid-

for immediate cPe credit, take the test now online at > www.drugtopics/cpe Once there, click on the link below Free CPE Activities



1. results of randomized clinical trials evaluating opioids for adult pain have shown they are

a. Effective for pain lasting 12 weeks or less.b. Effective for pain lasting more than 12 weeks.c. Effective for pain lasting more than 12 weeks

but less than 1 year.d. Effective for pain lasting more than 1 year.

2. opioids are prescribed for noncancer-related pain in

a. 1 in 3 adults. b. 1 in 4 adults.c. 1 in 5 adults. d. 1 in 6 adults.

3. since 1999, opioid deaths from illicit opioids and misuse of prescription opioids have

a. Decreased by one-half. b. Doubled.c. Decreased by one-third. d. Tripled.

4. Which of the following statements is true regarding the 2016 guideline for Prescribing opioids for chronic Pain?

a. Nonpharmacologic therapy is preferred for first-line treatment of adult noncancer–related chronic pain.

b. Extended-release/long-acting opioids should always be prescribed with immediate-release opioids in treatment of adult noncancer–related chronic pain.

c. Treatment of acute pain should be treated with at least a 7-day supply of opioids to maximize pain relief.

d. opioid dosages >50 mmE/day require justification.

5. neuropathic pain is optimally treated with which of the following medications?

a. Acetaminophen b. ibuprofenc. morphine d. pregabalin

6. What is the optimal timeframe for initiating extended release/long-acting opioids for a patient who is having continuous pain with appropriate use of immediate-release opioids for chronic noncancer pain?

a. 3 days b. 7 days c. 10 days d. 14 days

7. an adult patient with chronic mid-upper

back pain due to stenosis unable to undergo corrective surgery because of comorbidities has been taking morphine 15 mg every 6 hours for 6 weeks. she takes 3 tablets daily with some but not complete pain relief. her primary care physician asks for your recommendation on an appropriate extended-release/long-acting opioid to prescribe because he feels inexperienced with opioid medications. Which of the following would be most appropriate therapy to initiate?

a. morphine extended-release/long-acting 20 mg every 12 hours

b. Transdermal fentanyl 25 µg patch applied every 72 hours

c. methadone 15 mg every 12 hoursd. oxycodone extended release/long acting 20

mg every 12 hours

8. Which of the following statements about patients who require more than 50 mme/day is true?

a. Avoid increasing beyond this doseb. reassess whether opioid treatment is the best

approachc. Justify a decision to titrate beyond this dosed. risk of opioid overdose is increased up to 8.9

times.

9. the recommendations provided in the 2016 guideline for Prescribing opioids for chronic Pain are primarily

a. Level 1 – randomized clinical trials or overwhelming evidence from observational trials

b. Level 2 – randomized clinical trials with important limitations or exceptionally strong evidence from observational trials

c. Level 3 – observational studies or randomized clinical trials with notable limitations

d. Level 4 – clinical experience and observations or studies with major limitations

10. Which of the following statements is true about the expected benefits of opioids?

a. complete pain relief is primary goal.b. improved function is primary goal.

c. Long-term opioid use improves pain and function.

d. Functional improvement only occurs with complete pain relief.

11. Which of the following opioid adverse effects and mitigation recommendation is accurate?

a. A stool softener/stimulant should be used to prevent constipation in all patients.

b. if confusion occurs, the patient should immediately contact the prescriber.

c. if drowsiness occurs, tolerance will typically develop and it will cease.

d. Dry mouth is transient and will resolve in 2–3 days.

12. risks to household members and other individuals if opioids are intentionally or unintentionally shared can be minimized by all of the following except:

a. storage in a locked locationb. safe disposal at the community’s drug-take

back programc. use of naloxone for overdose reversald. regular urine drug testing of patient

13. a patient newly starting on opioids for chronic pain asks you about driving. Which of the following statements is most accurate about opioids impairment of safely operating a vehicle?

a. impairment occurs most commonly when opioids are initiated, doses are increased, or with other central nervous system depressants.

b. impairment typically only occurs with opioid initiation.

c. impairment only occurs with dose changes (ie, increases or decreases).

d. impairment only occurs with concurrent alcohol use.

14. all of the following are considered at high risk for opioid-related harms, such as overdose, except

a. A 73-year-old woman with congestive heart failure

eration of educating, offering, and/or dis-pensing naloxone (based on available state laws) can be prudent to prevent opi-oid abuse, particularly in those patients at high risk for overdose or potential diver-sion within their home. Additionally, the pharmacist should discuss proper use, side effects and management, expecta-tion about medication fills and require-ments for refills, dangers of stockpiling

unused medication, and safe storage and disposal to prevent diversion or misuse.

ConclusionWith the opioid overdose epidemic occur-ring in the US, an approach to protecting the public’s health and preventing opioid overdose is needed. CDC guidelines for prescribing opioids for chronic pain provide recommendations on determining when to

use opioids; optimal prescribing of opioids; and appropriate assessment of risk and harms of opioids. Pharmacists and phar-macy technicians are poised to assist the healthcare team and patients to safely use opioids for treatment of chronic pain.

References are available online at www.drugtopics.com/cpe. •


For PhArmAcisTs

TesT quesTions



b. A 56-year-old man with cirrhosis awaiting a liver transplant

c. A 32-year-old women with a history of depressiond. A 49-year-old man with postherpetic neuralgia

15. a 32-year-old woman who had been taking opioids for fi bromyalgia has just become pregnant. Which of the following is the best recommendation for opioid therapy?

a. refer patient to specialist to slowly taper the woman off opioids

b. continue opioid therapy but increase monitoring of the patient and fetus

c. use injectable naloxone along with a rapid taper of opioids

d. continue opioid therapy because the fetus is in fi rst trimester and risks are minimal

16. assessing risk factors for opioid-related harms should be done

a. At initiation of opioidsb. periodically during opioid therapy

c. Both at initiation and during opioid therapyd. only in patient with known comorbid conditions

17. a review of the patient’s profi le within a prescription drug monitoring program can allow the pharmacy team to

a. identify patients who have multiple providers prescribing opioids

b. Evaluate total opioid dosagesc. Evaluate other medications that may increase

risk of opioid overdosed. All of the above

18. Which of the following statements about using urine drug testing to assess risk and address harms of opioid use is true?

a. provides information about drug use that is not reported by the patient.

b. provides information about the opioid amount used in the last 72 hours.

c. Both natural and synthetic opioids can be detected using urine drug tests.

d. use of confi rmatory drug tests should be used

with when immunoassay is positive.

19. the 2016 guideline for Prescribing opioids for chronic Pain recommends offering naloxone to which of the following groups of patients?

a. All patients receiving opioidsb. patients taking benzodiazepines and opioidsc. patients taking ≥40 mmE/dayd. patients ≥65 years of age

20. Which of the following statements best describes the role of the pharmacist in managing patients receiving opioids for chronic pain?

a. pharmacists can evaluate and identify risks for opioid-use disorder and overdose by assessing prescriptions and patients for red fl ags.

b. pharmacists can identify patients who may not be optimally treated for their chronic pain.

c. pharmacists can provide drug information and recommendations for treatment of chronic pain to providers.

d. All of the above

1. Which of the following statements is an important principle of treating chronic pain?

a. Nonpharmacologic therapy is preferred because opioids have a small-to-moderate benefi t, uncertain long-term benefi ts, and serious risks.

b. When nonpharmacologic therapy alone is not enough, opioids should be used.

c. if opioids are used, then nonpharmacologic or nonopioid therapy should be discontinued.

d. pain is expected to completely disappear with treatment.

2. chronic neuropathic pain is optimally treated with which of the following medication types?

a. Analgesics, like acetaminophenb. Anticonvulsants, like pregabalinc. Nonsteroidal anti-infl ammatories, like

ibuprofend. opioids, like morphine

3. Which of the following statements about treatment of acute pain with opioids is true?

a. opioid use in acute pain has been associated with long-term opioid use.

b. Three days of opioid treatment is often not suffi cient for typical postsurgical acute pain.

c. Extended-release/long-acting opioids should be used for acute pain.

d. post injury, patients should receive enough opioids to have for at least 2 weeks.

4. risks to household members and other individuals if opioids are intentionally or unintentionally shared can be minimized by all of the following except:

a. storage in a locked location

b. safe disposal at the community’s drug-take back program

c. use of naloxone for overdose reversald. regular urine drug testing of patient

5. the 2016 guideline for Prescribing opioids for chronic Pain recommends offering naloxone to which of the following groups of patients?

a. All patients receiving opioidsb. patients taking benzodiazepines and opioidsc. patients taking ≥40 mmE/dayd. patients ≥65 years of age

6. a review of the patient’s profi le within a prescription drug monitoring program can allow the pharmacy team to

a. identify patients who have multiple providers prescribing opioids.

b. Evaluate total opioid dosages.c. Evaluate other medications that may increase

risk of opioid overdose.d. All of the above

7. assessing risk factors for opioid-related harms should be done:

a. At initiation of opioidsb. periodically during opioid therapyc. Both at initiation and during opioid therapyd. only in patient with known comorbid conditions

8. a common red fl ag that a patient may be struggling with an opioid-use disorder or diverting medications includes which of the following?

a. Atypical quantity and directions on a prescription

b. credit card payments for opioids

c. consistent prescription fi ll datesd. previous prescriptions for different opioids by

same prescriber

9. Which of the following is a best practice for pharmacy technicians when fi ling an opioid prescription?

a. Validate prescriber DEA registration numbertb. review pDmp for multiple prescribers,

concurrent benzodiazepines or other controlled substances, and timing of prescription fi lls

c. conduct any calls to prescribers about prescription questions or discussions with pharmacist about concerns away from the patient

d. All of the above

10. Which of the following situations does not accurately describe an appropriate referral to the pharmacist before the patient-counseling portion of the visit?

a. patient describes that they are not receiving pain relief from their opioid prescription; refer to pharmacist for consideration of optimal pain management

b. A patient with skin tracks on arm; refer to pharmacist for consideration of risks and discussion of naloxone use

c. A patient with questions about obtaining opioid prescription early because of any upcoming trip out of the country; refer to pharmacist to evaluate risks of diversion and patient education

d. A patient who has questions about managing constipation; show the patient the available laxatives in the over-the-counter aisle, no pharmacist referral is needed

For PhArmAcY TEchNiciANs




1. Nahin rL. Estimates of pain prevalence and severity in adults: united states, 2012. J Pain. 2015;16(8):769–780.

2. guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American pain society and American Academy of pain medi-cine. http://americanpainsociety.org/uploads/edu-cation/guidelines/chronic-opioid-therapy-cncp.pdf. Accessed January 12, 2017.

3. chou r, Deyo r, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence report/Technology Assessment No. 218. Agency for Healthcare research and Qual-ity. https://www.effectivehealthcare.ahrq.gov/ehc/products/557/1971/chronic-pain-opioid-treatment-report-141205.pdf. Accessed January 12, 2017

4. Daubresse m, chang H, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the united states, 2000–2010. Med Care. 2013;51(10):870–878.

5. centers for Disease control and prevention. Vital signs: overdoses of prescription opioid pain relievers---united states, 1999—2008. MMWR. 2011;60(43);1487–1492.

6. rudd rA, seth p, David F, scholl L. increases in drug and opioid-involved overdose deaths–united states, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–1452.

7. Dowell D, Haegerich T, chou r. cDc guideline for prescribing opioids for chronic pain–united states, 2016. JAMA. 2016;315(15):1624–1645.

8. paice JA, portenoy r, Lacchetti c, et al. management of chronic pain in survivors of adult cancers: Amer-ican society of clinical oncology clinical practice guideline. J Clin Oncol. 2016;34(27):3325–3345.

9. National comprehensive cancer Network. Adult can-cer pain. Version 2.2016. https://www.nccn.org/pro-fessionals/physician_gls/pdf/pain.pdf. Accessed January 12, 2017.

10. Thorson D, Biewen p, Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Health care protocol. Inst Clin Syst Improv. 2014;Jan 2014.

11. National collaborating centre for cancer. opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. may 2012. http://www.mascc.org/assets/study-groups/publications/palliative_care_opioids_in_palliative_care.pdf. Accessed January 12, 2017.

12. chou r, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National institutes of Health pathways to prevention Workshop. Ann Intern Med. 2015;162(4):276–286.

13. Fransen m, mcconnell s, Harmer Ar, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:cD004376.

14. Fransen m, mcconnell s, Hernandez-molina g, reichenbach s. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;4:cD007912.

15. Hayden JA, van Tulder mW, malmivaara A, Koes BW. Exercise therapy for treatment of non-spe-cific low back pain. Cochrane Database Syst Rev. 2005;3:cD000335.

16. chamberlin KW, Holle Lm. management of common pain conditions encountered by pharmacists: osteo-arthritis; low back pain; fibromyalgia; sprains, strains, contusions; and generalized headaches. Drug Topics. 2013;157(8):48–60.

17. us Department of Health and Human services. Non-opioid treatments for chronic pain. https://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf. Accessed January 12, 2017.

18. Krebs EE, Lorenz KA, Bair mJ, et al. Development and initial validation of the pEg, a three-item scale assessing pain intensity and interference. J gen intern med. 2009;24(6):733–738.

19. ostelo rW, Deyo rA, stratford p, et al. interpreting change scores for pain and functional status in low back pain: towards international consensus regard-ing minimal important change. Spine (Phila Pa 1976). 2008;33(1):90–94.

20. pham T. pharmacology and therapeutics of pain medications: part 2. Drug Topics. 2013;157(6):52–62.

21. miller m, Barber cW, Leatherman s, et al. prescrip-tion opioid duration of action and the risk of uninten-tional overdose among patients receiving opioid ther-apy. JAMA Intern Med. 2015;175(4):608–615.

22. us Department of Veterans Affairs. VA/DoD clin-ical practice guidelines: management of opioid therapy (oT) for chronic pain. Washington, Dc: us Department of Veterans Affairs; 2010. http://www.healthquality.va.gov/guidelines/pain/cot. Accessed January 12, 2017.

23. Washington state Agency medical Directors’ group. AmDg 2015 interagency guideline on prescribing opioids for pain. olympia, WA: Washington state Agency medical Directors’ group; 2015. http://www.agencymeddirectors.wa.gov/guidelines.asp. Accessed January 12, 2017.

24. cDc. common elements in guidelines for prescribing opioids for chronic pain. Atlanta, gA: us Department of Health and Human services, cDc; 2015. http://www.cdc.gov/drugoverdose/prescribing/common-elements.html. Accessed January 12, 2017.

25. Berna c, Kulich rJ, rathmell Jp. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2015;90(6):828–842.

26. Department of Veterans Affairs/Department of Defense. Tapering and discontinuing opioids. http://www.healthquality.va.gov/guidelines/pain/cot/opi-oidTaperingFactsheet23may2013v1.pdf. Accessed

January 12, 2017.

27. cDc. pocket guide: tapering opioids for chronic pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed January 12, 2017.

28. Kral LA. opioid tapering: safely discontinuing opi-oid analgesics. http://www.nhms.org/sites/default/files/pdfs/safely_Tapering_opioids.pdf. Accessed January 12, 2017.

29. prescription Drug monitoring program Training and Technical Assistance center. prescription drug mon-itoring frequently asked questions. http://www.pdmpassist.org/content/prescription-drug-monitor-ing-frequently-asked-questions-faq. Accessed Jan-uary 12, 2017.

30. state of connecticut Department of consumer pro-tection. prescription monitoring program. www.ct.gov/dcp. Accessed January 12, 2017.

31. Holle Lm, chamberlin K. regulatory and ethi-cal issues in pain management. Drug Topics. 2013;157(7):58–66.

32. paquin Am, Zimmerman K, rudolph JL. risk versus risk: a review of benzodiazepine reduction in older adults. Expert Opin Drug Saf. 2014;13(7):919–934.

33. American psychiatric Association. opioid use dis-order diagnostic criteria. Diagnostic and Statistical Manual of Mental Disorders (Dsm-V). http://pcss-mat.org/wp-content/uploads/2014/02/5B-Dsm-5-opioid-use-Disorder-Diagnostic-criteria.pdf. Accessed January 12, 2017.

34. substance Abuse and mental Health services Administration (sAmHsA). Find help and treatment. https://www.samhsa.gov/find-help. Accessed Jan-uary 12, 2017.

35. prescribe to prevent: prescribe naloxone, save a life. http://prescribetoprevent.org/. Accessed January 12, 2017.

36. opioid overdose prevention programs provid-ing naloxone to laypersons–united states, 2014. Morb Mortal Weekly Rep; 2015;64(23):631–635. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm. Accessed January 12, 2017.

37. state of connecticut Department of consumer pro-tection. opioid overdose prevention/naloxone (Nar-can) initiative. http://www.ct.gov/dmhas/cwp/view.asp?a=2902&q=509650. Accessed January 12, 2017.

38. American Academy of pain management. co-pre-scribing of naloxone in conjunction with opioid ther-apy. http://blog.aapainmanage.org/co-prescribing-of-naloxone-in-conjunction-with-opioid-therapy/. Accessed January 12, 2017.

39. Ensuring appropriate opioid management in a com-munity pharmacy setting. Pharm Lett. 2016;course 214. http://pharmacistsletter.therapeuticresearch.com/ce/cecourse.aspx?pc=16-214&AspxAutoDetectcookiesupport=1. Accessed January 12, 2017.

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